HL7 Europe Hospital Discharge Report
0.1.0-ballot - draft 150

This page is part of the HL7 Europe Hospital Discharge Report (v0.1.0-ballot: STU 1 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Example Bundle: Bundle: complete HL7 Europe Hospital Discharge Report (1)

Document Subject

Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier)

Other Id:Medical record number/8121c77e7bf9
Contact Detail

Document Content

Admission evaluation

Mr. Luigi De Luca, a 57-year-old male, was admitted on 1st April following a pre-diabetic episode characterized by episodes of fatigue, polyuria, and increased thirst. Recent routine blood tests showed elevated fasting blood glucose and HbA1c levels that required further investigation.

When Mr De Luca arrived in the morning we recorded a fasting blood glucose level at 180 mg/dL. His HbA1c level was 7.8%. He seemed to be dehydrated, so that he immediately was sent to the ward for a full breakfast and fluid substitution.

Family History

Mr. Luigi has a family history of diabetes (type 2, mother and maternal grandmother).

Vital signs

Vital signs1st April10th April
Body weight109 kg108 kg
Body height177 cm
Blood Pressure155 / 95 mmHg150 / 90 mmHg

Tobacco use

The patient smokes "a few" cigarettes per day.

Hospital Course

During the hospital stay from 1 to 10 April, Mr. De Luca underwent a series of diagnostic tests, consultations and initial treatment.

Throughout his hospital stay, Mr. De Luca was monitored closely. His blood sugar levels improved modestly with the introduction of Metformin, and no acute complications were observed.

Significant Observation Results

Blood Glucose Monitoring Regular monitoring of fasting blood glucose levels and random blood glucose levels. Fasting glucose levels consistently ranged between 140-180 mg/dL.
DateFasting glucose [Moles/volume] in BloodRange
1 April 2025180 mg/dL70 to 99 mg/dL
2 April 2025140 mg/dL70 to 99 mg/dL
3 April 2025150 mg/dL70 to 99 mg/dL
5 April 2025140 mg/dL70 to 99 mg/dL
HbA1c Test: An HbA1c level of 7.2%, confirming the diagnosis of Type 2 Diabetes Mellitus.
DateHemoglobin A1c [Mass/volume] in BloodRange
1 April 20257.2%< 5.7%
Oral Glucose Tolerance Test (OGTT): This test further confirmed impaired glucose tolerance.
DateGlucose [Mass/volume] in Serum or Plasma --1 hour post dose glucoseRange
2 April 2025180 mg/dL70 to 99 mg/dL

Significant procedures

Lifestyle Consultation: Mr. De Luca met with a dietitian to discuss necessary changes in his diet, focusing on a low glycemic index diet and the need to monitor carbohydrate intake. He was also advised to engage in regular physical activity.

Diabetes Education: Mr. De Luca attended educational sessions on diabetes management, including the importance of regular blood sugar monitoring, recognizing hypoglycemia and hyperglycemia symptoms, and foot care.

Starting Pharmacotherapy with Metformin.

Medications

Metformin 500 mg twice daily was started as the first-line treatment to help control blood glucose levels.
Medication administrationsDose/FrequencySNOMED
Metformin, oral tbl500 mg, twice / day765507008
Multivitaminesdaily

Follow-up

Follow-upActivitySNOMED
Endocrinology ClinicFollow-up appointment in 2 weeks to assess response to treatment306118006 Referral to endocrinology service (procedure)
Dietitian ConsultationAppointment in 1 month for further dietary planning103699006 Referral to dietitian (procedure)
Routine Blood testsRepeat HbA1c in 3 months43396009 Hemoglobin A1c measurement (procedure)

Diagnosis at Discharge

Discharge DiagnosesCodes
Type 2 Diabetes Mellitus – Newly diagnosed.
  • Type 2 diabetes mellitus E11 (ICD-10)
  • Diabetes mellitus type 2 (disorder) 44054006 (SNOMED)

Hospital Discharge Instructions

Instructions at Discharge to Mr. De Luca
  • Continue home glucose monitoring and to maintain a log for review at follow-up appointments.
  • Continue with the prescribed medication and lifestyle changes.
  • Monitor blood sugar levels at home regularly.
  • Adhere to the diabetic diet plan.
  • Stay physically active, with at least 30 minutes of moderate exercise most days of the week.
  • Return to the emergency department for any signs of hyperglycemia (e.g., excessive thirst, urination, confusion) or hypoglycemia (e.g., sweating, shakiness, confusion).

Additional Resources Included in Document

Entry 2 - fullUrl = urn:uuid:b01a2623-e219-41d2-8e78-1fa1439751d0

Resource Patient:

Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier)

Other Id:Medical record number/8121c77e7bf9
Contact Detail

Entry 3 - fullUrl = urn:uuid:7c9a2bf1-507f-4d43-b06e-d78e9670379d

Resource Encounter:

status: completed

class: inpatient encounter

serviceType: No display for Encounter.serviceType (concept: Diabetes mellitus screening (procedure))

subject: Bundle: identifier = Provider number; type = document; timestamp = 2025-04-29 14:00:00+0000

serviceProvider: Bundle: identifier = Provider number; type = document; timestamp = 2025-04-29 14:00:00+0000

Entry 4 - fullUrl = urn:uuid:74403dd8-bb1b-45f9-bb69-e843dfaf45e9

Resource PractitionerRole:

practitioner: Bundle: identifier = Provider number; type = document; timestamp = 2025-04-29 14:00:00+0000

organization: Bundle: identifier = Provider number; type = document; timestamp = 2025-04-29 14:00:00+0000

Entry 5 - fullUrl = urn:uuid:0710d9e7-3f1a-4e16-a9b3-5c991fe23c95

Resource Practitioner:

name: Augusto Zucchero-Combattente

telecom: augusto@casasgiuliana.osp.venetia.it

Entry 6 - fullUrl = urn:uuid:a61a91f8-b8f2-4947-9a64-5165ea380a38

Resource Organization:

name: Casa di cura Villa S. Giuliana

Contacts

-Address
*Verona 37128 it

Entry 7 - fullUrl = urn:uuid:a5bf69e4-24db-48a8-9eda-71516dcaf1d9

Resource Condition:

clinicalStatus: Active

code: Type 2 diabetes mellitus

subject: Bundle: identifier = Provider number; type = document; timestamp = 2025-04-29 14:00:00+0000

onset: 2025-04-04

Entry 8 - fullUrl = urn:uuid:b84038f8-9541-4c5b-93b0-a7f1b8e55bd3

Resource CarePlan:

status: Active

intent: Plan

category: Diabetes clinical management plan

title: Diabetes Management Plan

subject: Bundle: identifier = Provider number; type = document; timestamp = 2025-04-29 14:00:00+0000

period: 2025-04-10 --> (ongoing)

activity

activity

activity

Entry 9 - fullUrl = urn:uuid:92ffc1fd-71ff-4d54-bc06-25d9e1e1fea0

Resource Procedure:

status: Completed

code: Lifestyle education (procedure)

subject: Bundle: identifier = Provider number; type = document; timestamp = 2025-04-29 14:00:00+0000

Entry 10 - fullUrl = urn:uuid:a74a3dca-92fa-4b71-8e70-89a07ac74bc3

Resource Procedure:

status: Completed

code: Diabetic education (procedure)

subject: Bundle: identifier = Provider number; type = document; timestamp = 2025-04-29 14:00:00+0000

Entry 11 - fullUrl = urn:uuid:53a8c3c3-5d1b-4950-87bc-fddae2ebc079

Resource Procedure:

status: In Progress

code: Metformin therapy (procedure)

subject: Bundle: identifier = Provider number; type = document; timestamp = 2025-04-29 14:00:00+0000

Entry 12 - fullUrl = urn:uuid:635c22e7-d7f1-45ad-9b4d-d4fe35239085

Resource FamilyMemberHistory:

status: Completed

patient: Bundle: identifier = Provider number; type = document; timestamp = 2025-04-29 14:00:00+0000

relationship: mother

Conditions

-Code
*Family history of diabetes mellitus type 2 (situation)

Entry 13 - fullUrl = urn:uuid:3fbdfbe1-9d70-47ec-ac05-3e30b063365a

Resource FamilyMemberHistory:

status: Completed

patient: Bundle: identifier = Provider number; type = document; timestamp = 2025-04-29 14:00:00+0000

relationship: maternal grandmother

Conditions

-Code
*Family history of diabetes mellitus type 2 (situation)

Entry 14 - fullUrl = urn:uuid:f0113857-b9b7-429b-8893-b645a38ae20a

Resource Observation:

status: Final

category: Vital Signs

code: Body weight

subject: Bundle: identifier = Provider number; type = document; timestamp = 2025-04-29 14:00:00+0000

effective: 2025-04-01

value: 109 kg (Details: UCUM codekg = 'kg')

Entry 15 - fullUrl = urn:uuid:065c918f-730a-47f8-938a-7ad54618037b

Resource Observation:

status: Final

category: Vital Signs

code: Body weight

subject: Bundle: identifier = Provider number; type = document; timestamp = 2025-04-29 14:00:00+0000

effective: 2025-04-19

value: 108 kg (Details: UCUM codekg = 'kg')

Entry 16 - fullUrl = urn:uuid:81783ae4-c36d-424f-8cea-fe7d3407a36b

Resource Observation:

status: Final

category: Vital Signs

code: Body height

subject: Bundle: identifier = Provider number; type = document; timestamp = 2025-04-29 14:00:00+0000

effective: 2025-04-01

value: 177 cm (Details: UCUM codecm = 'cm')

Entry 17 - fullUrl = urn:uuid:a19e48e1-2271-4cdb-9c76-b0626c7a5363

Resource Observation:

status: Final

category: Vital Signs

code: Blood pressure panel with all children optional

subject: Bundle: identifier = Provider number; type = document; timestamp = 2025-04-29 14:00:00+0000

effective: 2025-04-01

component

code: Systolic blood pressure

value: 155 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')

component

code: Diastolic blood pressure

value: 95 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')

Entry 18 - fullUrl = urn:uuid:fd7f7580-5788-45dd-88ec-dca615d69c7d

Resource Observation:

status: Final

category: Vital Signs

code: Blood pressure panel with all children optional

subject: Bundle: identifier = Provider number; type = document; timestamp = 2025-04-29 14:00:00+0000

effective: 2025-04-10

component

code: Systolic blood pressure

value: 150 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')

component

code: Diastolic blood pressure

value: 90 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')

Entry 19 - fullUrl = urn:uuid:67152b1b-0ffa-4b8f-8b6a-a3d71d4d58b6

Resource Observation:

status: Final

category: Social History

code: History of Tobacco use

subject: Bundle: identifier = Provider number; type = document; timestamp = 2025-04-29 14:00:00+0000

effective: 2025-04-01

value: Current smoker

note: Patient smokes a few cigarettes a day

Entry 20 - fullUrl = urn:uuid:bda0b497-c9f2-47ca-8339-da1d379cb2f4

Resource MedicationAdministration:

status: in-progress

subject: Bundle: identifier = Provider number; type = document; timestamp = 2025-04-29 14:00:00+0000

Dosages

-TextRouteDose
*500 mg, twice a dayOral route500 mg